AMERICAN INTERNATIONAL HEALTH ALLIANCE

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1 AMERICAN INTERNATIONAL HEALTH ALLIANCE CAPACITY BUILDING TO PREVENT MOTHER-TO-CHILD TRANSMISSION OF HIV IN UKRAINE UPDATE TO THE FINAL REPORT December, 2008 USAID Annual Program Statement Grant #: 121-G Eye Street, NW, Suite 350, Washington, DC Tel: (202) Fax: (202)

2 Update on the Capacity Building to Prevent Mother-to-Child Transmission Project Building on a highly successful model PMTCT-Plus program in Odessa funded by USAID and utilizing substantial local training capacity established in association with that effort, the USAIDfunded Capacity Building to Prevent Mother-to-Child Transmission Project worked with the Ukrainian Ministry of Health (MOH) and departments of health administration of eight key oblasts in a 30-month human and organizational capacity building effort that resulted in the reduction of HIV transmission to infants. The project was designed to contribute to USAID s overall goal of providing comprehensive PMTCT services to 90% of affected women in each oblast by When the project ended in the fall of 2007, a preliminary estimation of the MTCT rate in the Phase 1 PMTCT Group, conducted in October 2007, demonstrated an average decrease of 75% compared to the Phase 1 baseline group (6.1% and 18.5% respectively). Given the eighteen-month delay in officially confirming HIV status of infants, however, AIHA could only report the final outcomes of the project eight months later in The final report for the project was completed in the fall of 2007 and submitted to USAID in November of that year. At the time of the preparation of the close-out report, AIHA reported interim indicators, and continued to track those data for another eight months in order to definitively conclude that the project had achieved its ultimate outcome indicators of significantly reducing transmission rates in the target sites. Now that eighteen-months have elapsed, this update report provides final data on the outcomes of the project. The final data show a decrease of the MTCT rate from 21% to 6%. This means that the investment in a comprehensive PMTCT program resulted in 15% of cases of HIV/AIDS were averted among babies exposed to HIV/AIDS. Background The Capacity Building to Prevent Mother-to-Child Transmission Project project involved thirty-two health care institutions and community-based NGO s in the eight oblasts. The project was implemented in close cooperation with other governmental and nongovernmental organizations, United States Government (USG)-funded PMTCT projects and other international agencies. The project s human and organizational capacity building included: Technical assistance in the development of comprehensive community-based PMTCT operational plans for each project site that effectively organized the activities of all key stakeholders including the non-governmental sector and; Support for the development of model programs and methodological centers of excellence in each oblast that incorporated quality improvement processes and evidence-based practices, reached large numbers of women directly, and in turn served as replication and training sites for the development of affiliated programs in underserved areas. The project s related workforce development included the following components: 2

3 On-site knowledge-based training utilizing the WHO/USG PMTCT Generic Training Package (GTP) adapted for Ukraine (AIHA with USAID E&E Bureau funding) and endorsed by the Ministry of Health (MOH); Clinical skills-based training at the South Ukrainian AIDS Education Training Center (SUAEC) for targeted caregivers from each site using curricula developed in Odessa for region-wide replication; PMTCT organizational workshops for decision-makers from each of the target oblasts in Odessa; Several Training-of-Trainers (ToT) using the adapted Ukrainian version of the WHO/USG PMTCT GTP for new oblast faculty to help insure sustainability of training programs in each oblast. Project implementation activities were staged in two phases of four target oblasts each. Project implementation activities for Phase 2 oblasts took into account challenges and lessons learned during Phase 1. Through the AIHA project, the target sites developed new operational frameworks to address the problem of PMTCT in a comprehensive, multisectoral manner, gained new knowledge and skills, developed and implemented a case management system to monitor and improve quality of care delivery, and trained healthcare professionals. The project created local capacities that will not only serve as a foundation for continued improvement in the target areas, but also as a model that can be utilized and disseminated across other regions in Ukraine. Specifically, this translated into: Strengthened ability of the Oblast Health Administrations to conduct PMTCT program assessments, establish task forces, and develop strategies and annual work plans. An expanded pool of trained healthcare providers, managers, and allied health staff providing quality, evidence-based PMTCT and related services. The pool was expanded to a total of 303 project caregivers who participated in 15 trainings. Strengthened the capacity-building infrastructure through project site support which established the Methodological Centers of PMTCT Excellence in each oblast. Improved early identification and referral of HIV-infected pregnant women (45% of HIV infected women were registered for prenatal care before the second trimester in the project PMTCT groups compare to 27% in baseline groups). Improved system of prenatal care to HIV+ women; decreased risk of MTCT HIV during labor and delivery; and improved post-natal care for infants and their HIV-infected mothers (84% of HIV infected women and 96% newborns received antiretroviral (ARV) prophylaxis in PMTCT groups compare to respectively 67% and 50% in baseline groups). Increased number of HIV-infected pregnant women receiving key non-medical services from non-governmental organizations (NGOs) (70% of HIV-infected pregnant women were referred to NGOs to receive non-medical care and support in PMTCT project groups compared to 7% in baseline groups). Wide dissemination of PMTCT results/lessons learned and coordination with broader maternal-and-child-health (MCH) and HIV/AIDS programs through regular meetings both locally and nationally. 3

4 Final Data Summary of PMTCT main clinical indicators improvement in Ukraine PMTCT project sites (as of June 30, 2008): Early identification and referral of HIV+ pregnant women improved (45% of HIV infected women were registered for prenatal care before the second trimester in PMTCT groups compared to 27% in baseline groups). The system of prenatal care to HIV+ women; labor & delivery practices; and post-natal care for infants and their HIV-infected mothers improved (84% of HIV infected women and 96% newborns received ARV prophylaxis in PMTCT groups compared to respectively 67% and 50% in baseline groups). The number of HIV-infected pregnant women receiving key non-medical services from NGOs increased (70% of HIV-infected pregnant women were referred to NGOs to receive non-medical care and support in PMTCT project groups compared to 7% in baseline groups). PMTCT results/lessons learned were disseminated and coordination with broader MCH and HIV/AIDS programs was implemented through regular meetings. The MTCT rate decreased from 21% in baseline group to 6% in the PMTCT group as a result of PMTCT interventions implemented during the project. Main Indicators Baseline Group (Average) PMTCT Group (Average) HIV test result known before delivery 99% 99% Prenatal registration during 1st trimester 27% 45% ARV prophylaxis for HIV+ pregnant women 67% 84% ARV prophylaxis for newborn 50% 96% C-section 11% 37% Replacement feeding 95% 96% Family planning counseling 46% 98% Referral to NGO/follow up care 7% 70% MTCT rate 21% 6% Detailed analysis of PMTCT main clinical indicators and trends in improvement at individual project sites: PHASE I PROJECT SITES Cherkassy: Increase of early prenatal registration of HIV-infected pregnant women (from 29% in baseline group to 50% in project group); Increase to 89% of ARV prophylaxis for mothers (compared to 47% in baseline group); Increase to 96% of ARV prophylaxis for newborns (compared to 35% in baseline group); Increase in elective C-section from zero (baseline group) to 27% in project group; 4

5 Increase in family planning counseling from 48% in baseline group to 100% in project group; Increase in referrals to NGO/follow up care from zero to 89% in project group. MTCT rate decreased from 19% (baseline group) to 7.6% in project group. Clinical improvements demonstrated in the chart below: PMTCT group/c herkassy: 26 pairs (01/01/ /30/2008) Baseline group/c herkassy: 17 pairs (01/01/ /01/2004) MT C T rate 7.6% 19% R eferral to NG O /follow up care 0% 89% F amily planning counseling Replacement feeding E pisiotomy (vaginal delivery) 37% 41% 48% 100% 96% 100% C section 0% 27% ARV prophylaxis for newborn 35% 96% ARV prophylaxis for mother 47% 89% Prenatal registration (1st trimester) 29% 50% HIV test result before delivery 100% 100% 0% 20% 40% 60% 80% 100% Bila Tserkva: Increase of early prenatal registration of HIV-infected pregnant women (from 36% in baseline group to 50% on project group); Increase of ARV prophylaxis for mothers (from 74% in baseline group to 92% in project group); ARV prophylaxis for newborns increased from 51% in baseline group to 92% in project group; Elective C-section increased from 2% to 42% in project group; Data demonstrated further increase in family planning counseling from 34% in baseline group to 92% in project group; 5

6 Increase of referral to NGO/follow up care from zero to 100% in project group. MTCT rate decreased from 20% (baseline group) to zero in project group Clinical improvements demonstrated in the chart below: PMTCT group/bila Tserkva: 12 pairs (01/01/ /30/2008) Baseline group/bila Tserkva: 53 pairs (01/01/ /01/2004) MTCT rate 0.0% 20% Referral to NGO/follow up care 0% 100% Family planning counseling Replacement feeding 34% 92% 92% 100% Episiotomy (vaginal delivery) 0% 25% C section 2% 42% ARV prophylaxis for newborn 51% 92% ARV prophylaxis for mother 74% 92% Prenatal registration (1st trimester) 36% 50% HIV test result before delivery 92% 100% 0% 20% 40% 60% 80% 100% Mykolayv: Increase of early prenatal registration of HIV-infected pregnant women (from 23% in baseline group to 47% in project group); Increase of ARV prophylaxis for mothers (from 57% in baseline group to 92% in project group); ARV prophylaxis for newborns increased from 85% in baseline group to 100% in project group; Elective C-section further increased from 8% to 20%; Data shows increase in family planning counseling from 46% in baseline group to 96% in project group; 6

7 Continuous increase of referrals to NGO/follow up care from 9% to 73% in project group. MTCT rate decreased from 19% (baseline group) to 8.3% in project group. Clinical improvements demonstrated in the chart below: PMTCT group/mykolayv: 49 pairs (01/01/ /30/2008) Baseline group/mykolayv: 47 pairs (01/01/ /01/2004) MTC T rate R eferral to NGO/follow up care 8.3% 19% 9% 73% Family planning couns eling Replacement feeding 46% 96% 100% 94% E pis iotomy (vaginal delivery) 11% 21% C section 8% 20% ARV prophylaxis for newborn 85% 100% ARV prophylaxis for mother 57% 92% Prenatal regis tration (1s t trimes ter) 23% 47% HIV tes t res ult before delivery 100% 100% 0% 20% 40% 60% 80% 100% Kryvoi Rig: Increase of early prenatal registration of HIV-infected pregnant women (from 30% in baseline group to 51% on project group); Stable (100%) provision of ARV prophylaxis for newborns; ARV prophylaxis for mothers in baseline group and project group is the same (96%); Increase of elective C-section from 8% to 47% in project group; Increase of family planning counseling from 52% in baseline group to 97% in project group; Continuous increase of referrals to NGO/follow up care from zero to 78% in project group. MTCT rate decreased from 16% (baseline group) to 8.4% in project group. 7

8 Clinical improvements demonstrated in the chart below: PMTCT group/kryvoi Rig: 96 pairs (01/01/ /30/2008) Baseline group/kryvoi Rig: 50 pairs (01/01/ /01/2004) MTCT rate 8.4% 16% Referral to NGO/follow up care 0% 78% Family planning counseling Replacement feeding 52% 97% 100% 100% Episiotomy (vaginal delivery) 26% 32% C section 8% 47% ARV prophylaxis for newborn ARV prophylaxis for mother 100% 100% 96% 96% Prenatal registration (1st trimester) 30% 51% HIV test result before delivery 100% 98% 0% 20% 40% 60% 80% 100% PHASE 2 PROJECT SITES Izmail: Increase in early prenatal registration of HIV+ pregnant women (from 41% in baseline group to 50% in project group; Case management analysis, using the installed PMTCT database tool, helped to analyze the decrease in ARV prophylaxis for mothers (67% in project group compare to 88% in baseline group), which was due to the fact that fact that two women were diagnosed with HIV too late in their pregnancy to receive ARV drugs. Increase to 83% of ARV prophylaxis for newborns (compared to 35% in baseline group); Increase in elective C-sections from 29% to 33% in project group; Increase in family planning counseling from 29% in baseline group to 100% in project group. 8

9 MTCT rate decreased from 6% (baseline group) to zero in project group. Clinical improvements demonstrated in the chart below: PMTCT group/izmail: 6 pairs (01/10/ /30/2008) Baseline group/izmail: 17 pairs (01/01/ /01/2004) MTCT rate Referral to NGO/follow up care 0.0% 6% 0% 0% Family planning counseling 29% 100% Replacement feeding 83% 100% Episiotomy (vaginal delivery) C section 0% 25% 33% 29% ARV prophylaxis for newborn 35% 83% ARV prophylaxis for mother 67% 88% Prenatal registration (1st trimester) 50% 41% HIV test result before delivery 100% 100% 0% 20% 40% 60% 80% 100% Feodosia: Increase in early prenatal registration of HIV-infected pregnant women (from 9% in baseline group to 33% in project group); Increase in ARV prophylaxis for mothers (from 36% in baseline group to 67% in project group); ARV prophylaxis for newborns increased from 18% in baseline group to 100% in the project group. Elective C-sections further increased from zero to 66%. Increase in family planning counseling from 45% in baseline group to 100% in project group; Increase in referrals to NGO/follow up care from zero to 66% in the project group. MTCT rate decreased from 18% (baseline group) to zero in project group. 9

10 Clinical improvements demonstrated in the chart below: PMTCT group/feodosia: 3 pairs (01/10/ /30/2008) Baseline group/feodosia: 11 pairs (01/01/ /01/2004) MT C T rate 0% 18% R eferral to NG O /follow up care 0% 66% F amily planning counseling Replacement feeding E pisiotomy (vaginal delivery) 0% 45% 100% 100% 100% 100% C section 0% 66% ARV prophylaxis for newborn 18% 100% ARV prophylaxis for mother 36% 67% Prenatal registration (1st trimester) 9% 33% HIV test result before delivery 100% 100% 0% 20% 40% 60% 80% 100% Kherson: Increase in early prenatal registration of HIV-infected pregnant women (from 25% in baseline group to 29% on project group); Increase in provision of ARV prophylaxis for newborns from zero to 100%, ARV prophylaxis for mother in project group increased to 71% compared to 50% in baseline group; Increase of elective C-sections from 25% to 28% in project group; Increase in family planning counseling from 50% in baseline group to 100% in project group; Increase of referrals to NGO/follow up care from 50% to 86% in project group. MTCT rate decreased from 50% (baseline group) to 14% in project group. Clinical improvements demonstrated in the chart below: 10

11 PMTCT group/kherson: 7 pairs (01/10/ /30/2008) Baseline group/kherson: 4 pairs (01/01/ /01/2004) MTCT rate 14.0% 50% Referral to NGO/follow up care 50% 86% Family planning counseling 50% 100% Replacement feeding 75% 100% Episiotomy (vaginal delivery) 0% 66% C section 28% 25% ARV prophylaxis for newborn 0% 100% ARV prophylaxis for mother 50% 71% Prenatal registration (1st trimester) 29% 25% HIV test result before delivery 100% 100% 0% 20% 40% 60% 80% 100% Chernigiv: Increase in early prenatal registration of HIV-infected pregnant women (from 21% in baseline group to 46% in project group); Increase in ARV prophylaxis for mothers (100% in project group compared to 87% in baseline group); 100% of ARV prophylaxis for newborns (compared to 79% in baseline group); Increase in elective C-sections from 18% to 30% in project group; Increase in family planning counseling from 66% in baseline group to 100% in project group; Referrals to NGO/follow up care increased from zero to 69%. MTCT rate decreased from 23% (baseline group) to 9% in project group. Clinical improvements demonstrated in the chart below: 11

12 PMTCT group/chernigiv: 13 pairs (01/10/ /30/2008) Baseline group/chernigiv: 38 pairs (01/01/ /01/2004) MTCT rate 9.0% 23% Referral to NGO/follow up care 0% 69% Family planning counseling Replacement feeding 66% 100% 100% 90% Episiotomy (vaginal delivery) C section 11% 7% 18% 30% ARV prophylaxis for newborn ARV prophylaxis for mother 79% 87% 100% 100% Prenatal registration (1st trimester) 21% 46% HIV test result before delivery 100% 94% 0% 20% 40% 60% 80% 100% Conclusion While many challenges and health care system obstacles remain in Ukraine to implement a comprehensive PMTCT program across the country, the USAID-funded AIHA project developed capacities in eight key Ukrainian regions to address human and organizational needs related to providing high-quality PMTCT services to women with HIV and babies exposed to HIV. As a result, Ukrainian caregivers in these oblasts are well positioned to sustain their capacities and seek out new opportunities to improve care to women with HIV and their children in the coming years. The eight oblasts are also well positioned to serve as both models and resources for the rest of Ukraine. Their success in a relatively short period of time across a significant number and diversity of sites sets an important benchmark for the country as a whole. By working closely with the Ukrainian MOH and the National AIDS Center, the project has both demonstrated the ability and developed the capacity for Ukraine to significantly reduce MTCT rates. Whether the tested approaches, organizational systems and training programs developed under the project are fully disseminated and scaled up nationally is dependent upon the commitment of the Ukrainian government and the donor community. The project also has important implications for other 12

13 countries in the NIS region which face similar HIV/AIDS related challenges and have common health system structures. We urge Ministries of Health in those countries and the international community to carefully consider the results of this project and seek the adoption and replication of the methods employed as expeditiously as possible. The final performance report and this update are a comprehensive overview of the AIHA PMTCT project in Ukraine between 2005 and Additional details and information can be found at 13

14 AMERICAN INTERNATIONAL HEALTH ALLIANCE CAPACITY BUILDING TO PREVENT MOTHER-TO-CHILD TRANSMISSION OF HIV IN UKRAINE FINAL REPORT Submitted to: USAID/Ukraine November 2007 USAID Annual Program Statement Grant #: 121-G Eye Street, NW, Suite 350, Washington, DC Tel: (202) Fax: (202)

15 TABLE OF CONTENTS Acknowledgments... 2 Acronyms & Abbreviations... 3 I. Executive Summary... 4 II. Program Overview... 6 III. Program Results IV. Conclusions Appendix A...41 Appendix B...44 Appendix C...46 Appendix D...60 ` 1

16 ACKNOWLEDGMENTS The (AIHA) wishes to express its sincerest gratitude to the Ukrainian and American project partners who gave so generously of themselves to the Capacity Building for Prevention of Mother-to-Child Transmission of HIV (PMTCT) Project in Ukraine. The project was successful because these individuals demonstrated the courage, commitment to change, patience, dedication, and hard work to gain new knowledge and skills, and a generous spirit of trust and collaboration. They made significant contributions to improving healthcare services for women with HIV, their babies and members of their families. AIHA also wishes to thank the United States Agency for International Development (USAID) for the opportunity and privilege of working on PMTCT capacity building in Ukraine and for its support of the project. And finally, AIHA gratefully acknowledges the contributions of dedicated staff in its Ukrainian and Washington, DC offices in managing and implementing the program and preparing the final performance report. AIHA has been privileged to have as its project director, Dr. Natalia Nizova, a nationally and regionally acknowledged expert in PMTCT. Dr. Nizova has been recognized for her contributions to scientific research on reproductive health, the development of national regulations on healthcare for women, and her outstanding achievements in medical education. Under the excellent leadership of Dr. Nizova, the Odessa team, which consisted of nationally recognized experts on maternal health, Dr. Bespoyasnaya, and Dr Tyapkin, assisted the partners in the project sites to make significant contributions to improving health care delivery services to women with HIV, their babies and members of their families. The staff of the South Ukrainian AIDS Education Center, under the leadership of Dr Posokhova, a pioneer in providing health care to pregnant women with HIV in the region, are among many dedicated practitioners who partnered with AIHA to achieve the project results. AIHA s mission is to advance global health through volunteer-driven partnerships that mobilize communities to better address healthcare priorities while improving productivity of care. Created in 1992 by a consortium of major healthcare provider associations and professional medical education organizations, AIHA establishes and manages programs and twinning partnerships between health-related institutions in the United States and their counterparts in Africa, Asia, Eurasia, and the Caribbean. The United States Agency for International Development (USAID), funded by the American people, provides economic and humanitarian assistance in more than 100 countries to provide a better future for all. Since 1992, USAID has provided more than $1.6 billion worth of technical and humanitarian assistance supporting Ukraine s democratic, economic, and social transition. 2

17 ACRONYMS & ABBREVIATIONS AIDS...Acquired Immunodeficiency Syndrome AIHA... ARV...Antiretroviral ART... Antiretroviral Therapy CD4...Cluster of Differentiation 4 ELISA...Enzyme-linked Immonosorbent Assay GFATM...Global Fund to Fight AIDS, Tuberculosis and Malaria GTP...Generic Training Package HAART... Highly Active Antiretroviral Therapy HIV...Human Immunodeficiency Virus IDUs...Injecting Drug Users ICT...Information, Communication and Technology MCH...Maternal and Child Health MOH...Ministry of Health MTCT... Mother-to-Child Transmission of HIV NGO...Non-Governmental Organization NIS...Newly Independent States PCR... Polymerase Chain Reaction PEPFAR...President s Emergency Plan for AIDS Relief PLWH...People Living with HIV PMTCT... Prevention of Mother-to-Child Transmission of HIV TOT... Training-of-Trainers SUAEC...South Ukrainian AIDS Education Center UNAIDS... Joint United Nations Program on HIV/AIDS UNICEF... United Nations Children s Fund USAID...United States Agency for International Development USG... United States Government VCT... Voluntary Counseling and Testing WHO...World Health Organization QA...Quality Assurance 3

18 I. EXECUTIVE SUMMARY Building on a highly successful model PMTCT-Plus program in Odessa funded by USAID and utilizing substantial local training capacity established in association with that effort, the USAID-funded Capacity Building to Prevent Mother-to-Child Transmission Project worked with the Ukrainian Ministry of Health (MOH) and departments of health administration of eight key oblasts in a 30-month human and organizational capacity building effort that will result in the reduction of HIV transmission to infants. The project was designed to contribute to USAID s overall goal of providing comprehensive PMTCT services to 90% of affected women in each oblast by Based upon interim indicators, we are confident that the project will achieve its ultimate outcome indicators of significantly reduced transmission rates. A preliminary estimation of the MTCT rate in the Phase 1 PMTCT Group, conducted in October 2007, demonstrated an average decrease of 75% compared to the Phase 1 baseline group (6.1% and 18.5% respectively). Given the eighteen-month delay in officially confirming HIV status of infants, however, reporting of final outcomes and whether the project achieved its overall target of a five to eight percent transmission rate will only occur in The project involved thirty-two health care institutions and community-based NGO s in the eight oblasts. The project was implemented in close cooperation with other governmental and nongovernmental organizations, United States Government (USG)-funded PMTCT projects and other international agencies. The project s human and organizational capacity building included: Technical assistance in the development of comprehensive community-based PMTCT operational plans for each project site that effectively organized the activities of all key stakeholders including the non-governmental sector and; Support for the development of model programs and methodological centers of excellence in each oblast that incorporated quality improvement processes and evidencebased practices, reached large numbers of women directly, and in turn served as replication and training sites for the development of affiliated programs in underserved areas. The project s related workforce development included the following components: On-site knowledge-based training utilizing the WHO/USG PMTCT Generic Training Package (GTP) adapted for Ukraine (AIHA with USAID E&E Bureau funding) and endorsed by the Ministry of Health (MOH); Clinical skills-based training at the South Ukrainian AIDS Education Training Center (SUAEC) for targeted caregivers from each site using curricula developed in Odessa for region-wide replication; PMTCT organizational workshops for decision-makers from each of the target oblasts in Odessa; Several Training-of-Trainers (ToT) using the adapted Ukrainian version of the WHO/USG PMTCT GTP for new oblast faculty to help insure sustainability of training programs in each oblast. 4

19 Project implementation activities were staged in two phases of four target oblasts each. Project implementation activities for Phase 2 oblasts took into account challenges and lessons learned during Phase 1. Through the AIHA project, the target sites developed new operational frameworks to address the problem of PMTCT in a comprehensive, multisectoral manner, gained new knowledge and skills, developed and implemented a case management system to monitor and improve quality of care delivery, and trained healthcare professionals. The project created local capacities that will not only serve as a foundation for continued improvement in the target areas, but also as a model that can be utilized and disseminated across other regions in Ukraine. Specifically, this translated into: Strengthened ability of the Oblast Health Administrations to conduct PMTCT program assessments, establish task forces, and develop strategies and annual work plans. An expanded pool of trained healthcare providers, managers, and allied health staff providing quality, evidence-based PMTCT and related services. The pool was expanded to a total of 303 project caregivers who participated in 15 trainings. Strengthened the capacity-building infrastructure through project site support which established the Methodological Centers of PMTCT Excellence in each oblast. Improved early identification and referral of HIV-infected pregnant women (45% of HIV infected women were registered for prenatal care before the second trimester in the project PMTCT groups compare to 27% in baseline groups). Improved system of prenatal care to HIV+ women; decreased risk of MTCT HIV during labor and delivery; and improved post-natal care for infants and their HIV-infected mothers (84% of HIV infected women and 96% newborns received antiretroviral (ARV) prophylaxis in PMTCT groups compare to respectively 67% and 50% in baseline groups). Increased number of HIV-infected pregnant women receiving key non-medical services from non-governmental organizations (NGOs) (70% of HIV-infected pregnant women were referred to NGOs to receive non-medical care and support in PMTCT project groups compared to 7% in baseline groups). Wide dissemination of PMTCT results/lessons learned and coordination with broader maternal-and-child-health (MCH) and HIV/AIDS programs through regular meetings both locally and nationally. While many challenges and health care system obstacles remain in Ukraine to implement a comprehensive PMTCT program across the country, the USAID-funded AIHA project developed capacities in eight key Ukrainian regions to address human and organizational needs related to providing high-quality PMTCT services to women with HIV and babies exposed to HIV. As a result, Ukrainian caregivers in these oblasts are well positioned to sustain their capacities and seek out new opportunities to improve care to women with HIV and their children in the coming years. The eight oblasts are also well positioned to serve as both models and resources for the rest of Ukraine. Their success in a relatively short period of time across a significant number and diversity of sites sets an important benchmark for the country as a whole. By working closely with the Ukrainian MOH and the National AIDS Center, the project has both demonstrated the ability and developed the capacity for Ukraine to significantly reduce 5

20 MTCT rates. Whether the tested approaches, organizational systems and training programs developed under the project are fully disseminated and scaled up nationally is dependent upon the commitment of the Ukrainian government and the donor community. The project also has important implications for other countries in the NIS region which face similar HIV/AIDS related challenges and have common health system structures. We urge Ministries of Health in those countries and the international community to carefully consider the results of this project and seek the adoption and replication of the methods employed as expeditiously as possible. This final performance report is a comprehensive overview of the AIHA PMTCT project in Ukraine between 2005 and The report describes the program approach, goals and objectives, main project components, achieved results and challenges. Additional details and information can be found at II. PROGRAM OVERVIEW Introduction In February 2005, USAID awarded the Capacity Building to Prevent Mother-to-Child Transmission of HIV/AIDS project, under its program on Mitigating the Impact of Those Affected by HIV/AIDS, to AIHA. The project was implemented within the framework of a 30- month grant period from February 3, 2005, through August 2, 2007, and was designed to contribute to USAID s overall goal of providing comprehensive PMTCT services to 90 percent of affected women in eight selected oblasts by The project focused on replicating the USAID funded Odessa PMTCT model program in eight targeted regions Dnipropetrovsk, Kyiv, Mykolayv, Cherkassy, Donetsk, Odessa, Kherson and Crimea to address their human and organizational capacity needs related to providing highquality PMTCT services. AIHA s PMTCT project in Odessa, Ukraine, initiated in 2000 and funded by USAID s Europe & Eurasia Bureau as a regional pilot initiative, was designed to improve systems of referral, treatment, and counseling for HIV-positive women. The project was also designed to serve as a model for replication in other Newly Independent States (NIS) as well as in other regions of Ukraine. The project s success resulted in the creation of a center of programmatic excellence, the South Ukrainian AIDS Education Center (SUAEC) in Odessa. The center has played a leading role in developing PMTCT guidelines, protocols, and case management systems readily adaptable to the needs of other communities and regions of the NIS. The Odessa pilot project achieved significant success in reducing the rate of MTCT by more than 75 percent between 2002 and 2004 and in facilitating replication of the Odessa model through capacity building activities throughout the NIS. The program was implemented in two phases. Phase 1 project sites included: Kyiv, Cherkassy, Dnipropetrovsk, and Mykolayv oblasts. The original phase 2 sites selected were Donetsk, Odessa, Kherson oblasts and Crimea. In December 2005, due to a request by the MOH and a high MTCT infection rate, USAID approved the replacement of Donetsk Oblast with Chernigiv Oblast in the project. 6

21 According to national and international experts, among all the countries of the former Soviet Union, Ukraine most vividly illustrates the speed with which the epidemic is moving beyond populations most at-risk and into the general population. The proportion of those infected through sexual transmission has increased from 14% of new cases ( ) to over 35% (January-June 2006). Among newly reported cases in the first six months of 2006, 41.5% were women, most of them in their peak of reproductive age (GFATM Sixth Call for Proposals Ukraine: HIV/AIDS Proposal). As a result, the numbers of children with AIDS and AIDS related deaths among children are continuing to grow: in 2003 these numbers were 68 and 38 respectively; in and 33 respectively, in and 36 respectively, in and 32 respectively (AIHA PMTCT final conference, May 15, National AIDS Center Presentation). (Please see Appendix D for more statistics on women and children and the HIV/AIDS epidemic in Ukraine). The AIHA project focused on specific regions within Ukraine which are the most affected by the epidemic and require immediate assistance. At the beginning of the project in 2005 the epidemiological situation in the targeted regions was the following: Chernigiv Oblast had a prevalence rate of per 100,000 (2005). The officially registered number of HIV cases is 843. The MTCT rate in the oblast is 25.6% (Informational Bulletin #24 of Ukrainian National AIDS Center). Dnipropetrovsk Oblast had a prevalence rate of per 100,000 (2005). The officially registered number of HIV cases by January 1, 2005 was 13,539. The MTCT rate in the oblast was 13% (2002). Mykolayiv Oblast had a prevalence rate of per 100,000 (2005). According to the MOH, the officially registered number of HIV cases by January 1, 2005 was 4,864. In 2003, the number of HIV positive women who delivered babies was 108. In 2004 this number increased by 37% and was 148. According to the Oblast Health Administration data, the MTCT rate in the oblast is 10.5%. Cherkassy Oblast had a prevalence rate of per 100,000 (2005). The officially registered number of HIV cases by January 1, 2005 was 1,771. Fifty seven HIV+ pregnant women were registered in 2004 in the oblast. The MTCT rate is 12% according to the Oblast Health Administration data. Crimea had a prevalence rate of per 100,000 (2005). The officially registered number of HIV cases was 5,575 (November, 2005). The MTCT rate was 11.3% (Crimea AIDS Center, November 2005). Kherson Oblast had a prevalence rate of per 100,000 (2005). The officially registered number of HIV cases was 1,855 (October, 2005). The MTCT rate in the oblast was 7.2% (Kherson AIDS Center, October 2005). Kiev Oblast has a prevalence rate of 88.1 per 100,000 (2005). The officially registered number of HIV cases by January 1, 2005 was 1,604. One hundred fifty seven HIV-positive pregnant women were registered in The MTCT rate is 8% according to the oblast health administration. Odessa Oblast had a prevalence rate of per 100,000 (2005). The officially registered number of HIV cases was 7,157 (January 2005). The MTCT rate in the oblast was 9.7% (Informational Bulletin #24 of Ukrainian AIDS Center, January 2005). 7

22 The project contributes to and is supportive of USAID/Ukraine s Special Objective 3 (SPO 3): HIV Transmission Among High-Risk Groups Reduced and Impact on Those Affected Lessened, from USAID/Ukraine s HIV/AIDS Strategy At the intermediate result (IR) level, the project contributes to IR 1: Strengthened Delivery of HIV/AIDS Information and Services and IR 3: Reduced Stigma and Discrimination Associated with HIV Infection and AIDS. Project Overview The overall goal of the project was to reduce HIV transmission from mothers to their infants in the target oblasts. Achievement of this goal will be measured by a decrease in the percent of infants born to HIV-positive mothers who test positive for HIV at 18 months. The overall target is to reach a five to eight percent transmission rate. While the project design includes systematic monitoring of a number of interim indicators and preliminary estimations of outcome indicators based upon the initial mother-child cohorts, Ukrainian health regulations only provide for confirmation of HIV status at 18 months of age and therefore reporting of final outcome results will occur at the end of 2008, after the project has ended. The project was designed to contribute to USAID s overall goal of providing comprehensive PMTCT services to 90% of affected women in each oblast by More specific goals and objectives of the project are outlined below. Goal #1: To strengthen human and organizational capacity to develop, deliver and sustain services to prevent mother-to-child transmission of HIV. Objectives: Strengthen ability of eight target Oblast Health Administrations to conduct PMTCT program assessments, establish community-based PMTCT task forces, and develop comprehensive PMTCT strategies and related annual workplans. 8

23 Expand the pool of trained healthcare providers, managers and allied professionals delivering quality, evidence-based PMTCT and related services. Strengthen the organizational and human resource capacity-building infrastructure of each oblast through establishment of a methodological center of PMTCT excellence 1 and affiliated centers that provide continuous training related to PMTCT. Establish quality improvement processes in each of the methodological PMTCT centers of excellence and affiliated centers. Increase awareness and knowledge among targeted healthcare workers of proper infection control procedures to prevent occupational exposure to HIV. Goal #2: To facilitate the rapid scale-up of quality PMTCT and related services available to HIV-positive women in each of the eight target oblasts. Objectives: Improve the early identification and referral of HIV-infected pregnant women to increase the numbers of identified HIV-infected pregnant women reached with case management services and involved in comprehensive PMTCT program activities. Improve the system of prenatal care and implement necessary drug regimens (based on the latest WHO protocols for Commonwealth of Independent States, 2004) that are possible in Ukraine to prevent HIV vertical transmission. Decrease the risk of HIV transmission from mother-to-child during labor and delivery, in accordance with WHO protocols. Improve post-natal care for newborns/infants and HIV-positive mothers through family planning services post-delivery and appropriate treatment and follow-up care according to WHO protocols, including referral to HIV/AIDS clinics for Highly Active Antiretroviral Therapy (HAART) where appropriate. Goal #3: To improve and expand collaboration between the healthcare system and NGOs providing non-medical services to risk groups. Objectives: Increase the participation in PMTCT-related activities of non-medical NGOs providing services to at-risk groups. Increase the number of HIV-positive pregnant women receiving key non-medical services from relevant NGOs. Goal #4: To expand the potential impact of the PMTCT programs and avoid duplication of efforts through close coordination with related USG-funded and other donor-funded programs. Objectives: Facilitate coordination with broader MCH and HIV/AIDS programs through regular strategy and coordination meetings with MOH, target oblasts, and key donors including USAID, WHO, UNICEF, GFATM sub-grantees, etc. 1 Terminology requested by Ministry of Health 9

24 Increase dissemination of PMTCT results/lessons learned nationally, regionally and internationally. Technical Approach: PMTCT Capacity Building Roll-out Strategy for Eight Target Regions Over the project period of 30 months, AIHA assisted the eight target oblasts to address their human and organizational capacity needs related to providing high-quality PMTCT services to HIV-positive women in need of such services. The project was built upon the lessons learned in the highly successful, USAID funded, model PMTCT-Plus program previously developed by AIHA in Odessa and utilized the substantial local experience and training capacity developed at the South Ukrainian AIDS Education Center, in association with that effort. Key project elements included: Technical assistance and training in the development of comprehensive community-based PMTCT operational plans for each project site that effectively organized the activities of all key stakeholders including the non-governmental sector. Technical assistance and training in support of the development of model programs and methodological centers of excellence in each oblast that incorporated quality improvement processes and evidence-based practices, reached large numbers of women directly, and in turn served as a replication and training site for the development of affiliated programs in underserved areas. Organization of a quality improvement collaborative through a regular series of workshops and group trainings that allowed implementation teams from all project sites to work and learn together, thus allowing for more rapid adaptation and spread of lessons learned, the sharing of strategies for dealing with common challenges and development of experience that can be utilized by the Ministry of Health to further spread the PMTCT program to other sites in Ukraine. This collaborative was further enhanced by close cooperation with other international organizations and people living with HIV (PLWH)- NGOs implementing GFATM programs on psycho-social support to women with HIV and their babies in the target oblasts. Staging of project implementation activities in two phases of four target oblasts each. Phase 1 involved implementation of the project in four initial oblasts: Cherkassy, Dnipropetrovsk, Kyiv and Mykolayv. Phase 2 activities began one year later and included the following oblasts: Crimea, Chernigiv, Kherson and Odessa. Project implementation activities for Phase 2 oblasts took into account challenges and lessons learned during Phase 1. The principal implementation steps for the project and its component elements are described below: Program Initiation Within 60 days of project award, AIHA held two meetings: (a) a coordination meeting with MCH/MOH, National AIDS Center representatives, and international and national organizations implementing PMTCT projects in Ukraine to develop collaborative linkages and synergy between programs so as to avoid duplication and build upon each other s successes; and (b) a project launch meeting with key representatives (directors of regional AIDS Centers, chief oblast Ob/Gyns and pediatricians, representatives of key local NGOs) from Phase 1 participating 10

25 oblasts, MCH/MOH, Ukrainian National AIDS Center representatives to review the Ukraine PMTCT project and the key elements of implementation. Special attention was given to preparation for initiating base line data collection, organizing the initial community-based PMTCT task force and community meeting, identifying potential clinical sites for development as centers of excellence, and review of progress in the development of the oblast action plan to improve PMTCT services in their cities and oblasts. The workshop was built upon the considerable preliminary work that was achieved in AIHA s December 2003 workshop for policymakers from the MOH and eight target regions. Comprehensive, community-based operational plans for PMTCT Effective PMTCT programs require the coordination of a variety of MCH and HIV/AIDS-related services as well as significant outreach to high-risk populations (injecting drug users (IDU s) and commercial sex-workers) that are often difficult to reach. A community-based approach that engages key stakeholders, including the NGO community and advocacy groups for at-risk populations was an essential starting point for the development of a comprehensive strategy that in turn provided a road-map for the organization of care within each oblast. The following key action steps were formulated: In the beginning of the first project year key AIHA and Odessa staff conducted site assessment visits to each of the four Phase 1 oblasts and facilitated a community stakeholder workshop to discuss the importance of effective PMTCT, the potential for preventing transmittal, and the elements of a comprehensive, high-quality PMTCT program in close coordination with the MCH/MOH and other PMTCT projects. Community goals and objectives were developed. Following the stakeholder workshop, staff worked with oblast policymakers to finalize implementation plans for the project with specific goals, objectives and action steps regarding continuous outreach and engagement of the key stakeholders and the formation of a PMTCT community task force. Site assessment visits to Phase 2 sites took place in the beginning of the second project year. During the second project year project staff conducted mid-term visits to each of the target oblasts to meet with the PMTCT community task forces and to help with challenges they were encountering in implementing the local plans. In addition, the project staff followed-up with the local NGOs that participated in the initial workshop to ensure that outreach programs were improving early identification and referral of HIVpositive pregnant women, particularly from high-risk groups. At the end of the project, AIHA project staff facilitated final assessments in each oblast to review progress and discuss challenges, to share lessons learned from all the oblasts, and to identify future steps for covering gaps and sustainability approaches. The assessment provided an opportunity for community stakeholders to report on success stories and to discuss community concerns about and responses to the problem of MTCT. In addition, the assessment enabled local NGOs to inform the wider community of services they can provide and will in turn help the NGOs to disseminate information to the wider community. Assessments were planned and implemented in close coordination with the MCH/MOH and other international projects on PMTCT and related NGO programs. 11

26 Model Programs, Methodological Centers of Excellence and Related Training In order to contribute to increasing coverage in providing comprehensive services to HIVpositive women in Ukraine, the project developed a Methodological Center of PMTCT Excellence in each of the selected oblasts to serve the largest concentrations of women. Each center was comprised of both (a) the regional hospital that receives HIV-positive delivery referrals, and (b) a women s consultation center serving a district with a high percentage of highrisk women with close linkages to local NGOs, providing psychosocial support to women with HIV and their children. The hospitals have increasingly become the methodological centers of excellence for delivering babies of HIV-positive women and have assumed the role of a clinical training center for other professionals in the region. The women s consultation centers are becoming the key resource in the oblast on HIV counseling and testing and prenatal care. The hospitals and women s consultation centers work closely with the AIDS centers to ensure a continuation of case management services for women and babies. Each institution developed close working relationships with local NGOs to focus on vulnerable populations and coordinate early identification and referral to medical care of pregnant women from high-risk groups as well as ensure appropriate social support and follow up. Teams of healthcare workers from each center of excellence received extensive training under the project. AIHA provided technical support and workforce development for the establishment of centers and local governments assumed funding responsibilities, where available. The key action steps in developing the Methodological Centers of Excellence and related human capacity building for each oblast are outlined below: During initial project site assessments AIHA staff, in close coordination with MCH/MOH and oblast health officials, conducted extensive site visits and staff interviews and identified Methodological Centers of PMTCT Excellence in each project oblast. After the institutions had been selected, AIHA and oblast health officials assessed the specific training and related needs of each site and identified key health professionals to participate in the knowledge based trainings in each oblast and to attend the skills-based clinical workshop programs at the SUAEC in Odessa. Equipment and supply needs were assessed and AIHA staff assisted the organizations to document their needs and identify both local and outside sources to fill these gaps. During the mid-term assessments, project staff provided targeted on-site mentoring to counselors, Ob/Gyn and pediatric teams; assisted each center to review guidelines and procedures; monitored PMTCT database entry and verification and identified areas for quality improvement. At the end of Year 1 (Spring 2006), a workshop was organized in collaboration with the MOH, the oblast health administrations from each of the selected oblasts and the international organizations and NGOs involved in the target regions in the PMTCT program implementation. Representatives from each oblast reported on replication, results and challenges at the workshop, which took place in Kiev. The workshop assessed the results of the first year of implementation and was a forum for discussing the lessons learned in the replication effort, and synergy between different PMTCT projects implemented in the target oblasts. The workshop also served as a forum for assessing the implications for national legislation and regulatory policy as it relates to HIV/AIDS and MTCT, and for taking stock and identifying the gaps and further training needs of all the sites. 12